How we treat HER2-positive brain metastases

Overexpression of the human epidermal growth factor 2 (HER2)/neu glycoprotein receptor in breast cancer is associated with increased risk of brain metastases, especially in patients with advanced disease. Improvements in the treatment of HER2-positive breast cancer has led to prolonged survival of patients with advanced disease, but the prevention and management of central nervous system metastases still poses unique clinical challenges given the associated morbidity and mortality of this site of disease. HER2-positive brain metastases are treated with surgery, radiation (stereotactic radiosurgery or whole brain radiotherapy), and systemic therapies, and are best managed by an experienced multidisciplinary team. The present article aims to provide an overview to our approach to treatment of HER2-positive brain metastases, including a review of agents with central nervous system activity, as well as management suggestions for several nuanced clinical scenarios. •HER2-positive subtype of breast cancer is a risk factor for development of intracranial metastases in advanced disease.•Treatment paradigms for HER2-positive brain metastases include both local and systemic approaches.•Several anti-HER2-directed therapies that show intracranial activity should be used for systemic treatment of brain metastases.